Journal of Cardiology & Current Research
Carotid Artery Intimal-Medial Thickness and Left
Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease
Research Article
Abstract
Background: Carotid intima-media thickness (CIMT) is a non-invasive,
inexpensive, reliable marker of coronary artery disease (CAD). LV global
longitudinal strain function (LV GLS) can be accurately assessed by 2D speckletracking strain echocardiography (2D-STE).
Objectives: This study aimed to assess the relationship between carotid IMT
and left ventricular global longitudinal strain (LV GLS) assessed by 2D speckletracking strain echocardiography (2D-STE) in patients with CAD. It also aimed to
assess the ability of both LV global longitudinal strain (LV GLS) and carotid IMT
to predict CAD severity.
Methods: It included 156 patients with suspected CAD by history of angina
admitted electively for coronary angiography (CA). We excluded patients with
acute coronary syndrome and concomitant disease or drug therapy which affect
cardiac function. Patients underwent transthoracic echocardiography (TTE), 2-D
speckle tracking echocardiography (2D-STE), B-mode ultrasound of the carotid
arteries and coronary angiography. The patients were divided into two groups:
group 1 (106 patients) with significant (>70%) CAD, and group 2 (50 patients)
with non-significant CAD obstruction. Conventional 2D echocardiographic
examinations were done by using General Electric VIVID 9 with M4S transducer,
with a frequency of 1.5-4.3 MHz. Examinations included measurements of cardiac
dimensions and LV ejection fraction. Images were obtained in the apical long-axis,
four-chamber, and two chamber views for the global peak systolic longitudinal
strain (PSLS). Measurement of CIMT was performed at the far wall of the common
carotid artery (CCA) 1cm proximal to the bifurcation.
Volume 8 Issue 1 - 2017
Department of Cardiovascular, Faculty of Medicine, Zagazig
University, Egypt
*Corresponding author: Hanan Radwan, Department of
Cardiovascular, Faculty of Medicine, Zagazig University,
Egypt, Tel: 201066381472; Email:
Received: December 07, 2016 | Published: January 09,
2017
Results: There were significant increase in the mean CIMT and significant decrease
in GLS in group 1 compared to group 2 (1.43 ± 0.41 vs 0.72 ± 0.4, p < 0.001), and
(-12.2± 2.93 vs -16.65 ± 3.5, p < 0.001) respectively. The cut-off value for LVGLS
less than-15.8 % using ROC curve was a predictor of significant CAD with AUC
0.82, 95%CI 0.71-0.94, p< 0.001. The sensitivity, specificity and accuracy of GLS
for detecting significant CAD were 96.2%, 68.0%, and 87.2% respectively. The
cut-off value of the CIMT > 1.1 mm using ROC curve was a predictor of significant
CAD with AUC 0.89, 95% CI 0.81-0.96, p< 0.001. The sensitivity, specificity and
accuracy of mean CIMT were 92.5%, 84.0% and 89.7%. There was significant
negative correlation between global LVGLS and mean carotid IMT (r = -0.88, p<
0.0001 and positive correlation with EF (r = 0.37, p = 0.001).
Conclusion: Increased CIMT was associated with decreased LV function
assessed by 2D strain echocardiography. Decreased GLS and increased CIMT
were associated with significant CAD; So these findings support the use of CIMT
measurements to predict subclinical LV dysfunction and the risk of CAD.
Keywords: Carotid artery intimal-medial thickness; LV global longitudinal strain
function; Speckle tracking echocardiography; CAD
Introduction
The atherosclerotic process is a generalized process affecting
the arterial tree which begins in child-hood, progresses over
decades and may remain clinically silent in the majority of
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people. In the coronary arteries, it remains asymptomatic
until it progresses to cause a hemodynamically significant flow
limiting lesion leading to symptoms of myocardial ischemia.
However, a substantial proportion of patients progress abruptly
from unapparent disease to a myocardial infarction or possible
J Cardiol Curr Res 2017, 8(1): 00268
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
death, due to thrombus formation following acute rupture or
erosion of non-stenotic plaques [1]. Identification of patients at
high risk in the early phase is critical to allow for modification
of cardiovascular risk by effective preventive strategies. Coronary
angiography (CA) is currently considered the gold standard
for detecting obstructive coronary artery disease. However, its
inability to detect early atherosclerotic changes, its invasive
nature, as well as exposure to ionizing radiation, make it an
unattractive primary screening tool in preventive cardiology [2].
Ultrasound measurement of carotid intima-media thickness
(CIMT) has become a valuable tool for detecting and monitoring
progression of atherosclerosis [2]. The American College of
Cardiology Foundation/American Heart Association guidelines
recommend CIMT measurements for patients at intermediate
CVD risk [3]. The longitudinally arranged subendocardial fibers
are more vulnerable to ischemia due to their direct exposure
to the intraventricular blood pressure and the anatomy of the
coronary circulation [4-6]. As a result, longitudinal function is
impaired first in CAD. Measurements of longitudinal motion and
deformation are therefore, the most sensitive markers of coronary
artery disease especially in patients with severe coronary
stenosis, where intermittent ischemia may result in subtle forms
of stunning that may be detectable with strain measurements.
Severe CAD is known to lead to LV dysfunction. However, the
LV ejection fraction is usually normal at a relatively early stage
[7] which can be explained by that impairment in longitudinal
systolic function is known to be compensated by augmentation
of circumferential deformation. Global longitudinal peak systolic
strain (GLS) can be detected by two-dimensional speckle tracking
echocardiography (2D-STE) [4-6].
Aim of the Work
Copyright:
©2017 Mostafa et al.
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carotid arteries and coronary angiography. The patients were
divided into two groups: group 1 (106 patients) with significant
(>70%) CAD, and group 2 (50 patients) with non-significant CAD
obstruction.
Transthoracic echocardiographic (TTE)
Examination was done by using General Electric VIVID 9 with
M4S transducer, with a frequency of 1.5-4.3 MHz and high frame
rate (60-90 frame/s), Examinations included measurements of
cardiac dimensions and LV ejection fraction by M-mode method
[8].
Strain analyses
Two consecutive heart cycles at rest, from the three standards
apical planes (four-chamber, two-chamber, and long-axis), were
considered by conventional 2D gray scale echocardiography. In
each of the apical views, the endocardial contour was manually
drawn and tracking of deformation was automatically performed
by the software, once visual confirmation of good quality tracking
was given by the operator. The software algorithm automatically
segmented the LV into six equidistant segments and selected
suitable speckles in the myocardium for tracking. The software
algorithm then tracked the speckle patterns on a frame by frame
basis using the sum of absolute difference algorithm. Regional
longitudinal peak systolic strain (RLS) was measured in all
views between aortic valve opening and closing for the 6 basal,
6 midventricular, and 4 apical segments and 17th segment was
apical cap and averaged from the 17 segments to provide global
longitudinal peak systolic strain (GLS)8 (Figure 1A & 1B).
This study aimed to assess the relationship between carotid
IMT and left ventricular global longitudinal strain (LV GLS)
assessed by 2D speckle-tracking strain echocardiography
(2D-STE) in patients with coronary artery disease (CAD). It also
aimed to assess the ability of both LV global longitudinal strain
(LV GLS) and carotid IMT to predict CAD severity.
Patients and Methods
Patients
The study was done in cardiology department in Zagazig
University. It included 156 patients with suspected CAD by history
of angina and either resting ECG changes or positive exercise stress
test admitted electively for coronary angiography (CA). Exclusion
criteria were; patients with acute coronary syndrome, previously
known CAD as a history of myocardial infarction (MI), previous
coronary artery bypass grafting surgery (CABG) or percutaneous
coronary intervention (PCI), patients with LV systolic dysfunction
(EF < 45 %), patients with resting wall motion abnormalities,
atrial fibrillation, left bundle-branch block, severe valvular
disease, concomitant disease as connective tissue disease or drug
therapy which affect cardiac function and patients with poor
acoustic window unsuitable for speckle tracking echo. Patients
underwent transthoracic echocardiography (TTE), 2-D speckle
tracking echocardiography (2D-STE), B-mode ultrasound of the
Figure 1A: Left panel demonstrates apical four-chamber view.
Corresponding strain curves are shown in the right panel. GLS is
decreased with strain values of - 13.7 %.
Carotid ultrasound
The carotid ultrasound examination was carried out according
to the American Society of Echocardiography guidelines [9]. The
extracranial common carotid arteries (CCAs) were sequentially
assessed using a high-resolution 5- to 10-MHz linear-array
ultrasound transducer (GE-VingMed) by an experienced physician.
Patients were examined in the supine position with the head
angled approximately 45 degrees towards the contralateral side.
IMT measurements were synchronized with the QRS complex on
Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
the ECG. Measurements were made in each carotid artery at the
peak of the R wave where the lumen is widest. IMT was defined
as the distance between the lumen-intima and media-adventitia
borders of the vessel identified as a double line pattern in a
longitudinal image [10]. Measurement of CIMT was performed at
the far wall of the common carotid artery (CCA) 1cm proximal to
the bifurcation over an area of 10 mm of the distal CCA recorded
in longitudinal mode, ensuring the CCA was parallel to the
transducer surface (horizontal in the image). Focal zone was set
to the far CCA wall, and gain was adjusted high enough so echoes
were just observed in the lumen. The reader selected frames with
good perpendicular alignment and image quality and adjusted
IMT box position if necessary to ensure measurement of mean
CIMT over the distal 10 mm of the far wall of the CCA. For every
patient, mean IMT measurements were taken at the same phase
of the cardiac cycle (electrocardiography gated) on each artery
(right/left). All CIMT measurements from both arteries were
averaged to create mean CIMT. Plaque diameter was included in
the CIMT measurements if present in the areas of interest.
Figure 1B: Ball’s eye showed averaged GLS= -10.6%.
Copyright:
©2017 Mostafa et al.
to compare percentages. Pearson’s correlation coefficients were
used to assess the strength of relationship between continuous
variables. ROC curve was plotted to get cut off value, sensitivity
and specificity. A p value of less than 0.05 was considered
significant.
Results
The patients were divided into two groups, group 1 (106
patients) with significant CAD >70% stenosis, and group 2 (50
patients) with non significant CAD. Comparison of the basic
characteristic of the study population in patients with and
without significant coronary obstruction are summarized in
Table 1. Regarding age; it was 51.3 ± 8.8 in group 1 versus 53.7
± 5.8 in group 2, p=0.28. Sex and risk factors were comparable
in both groups in spite high prevalence of risk factors in patients
with significant CAD. Group 1 had significant decrease in GLS &
EF (-12.2 ± 2.93 vs -16.65 ± 3.5, p < 0.000), LVEF (62.5 ± 6.5 vs
66.1 ± 6.8, p =0.033) and significant increase in mean CIMT (1.43
± 0.41vs 0.72 ± 0.4, p < 0.000) compared to group 2.
Angiographic findings of the study population were summarized
in Table 2: 50 patients (32.1%) with non significant CAD-and 106
patients (67.9%) with significant CAD+, 102 patients (96.2%) had
LAD, 86 patients (64.2%) had LCX, 38 patients (35.8%) had RCA.
28 patients (26.4%) had SVD, 32 patients (30.2%) had DVD, 46
patients (43.4%) had TVD. Diagnostic accuracy of CIMT & GLS for
detetection of significant epicardial coronary stenosis (Table 3,
Figure 2 & 3); The optimal cutoff value of mean CIMT was > 1.1
mm [AUC 0.89, 95% CI 0.81-0.96, p < 0.000] and for GLS was <
-15.8% [AUC 0.82, 95% CI 0.71- 0.94 p < 0.000]. The sensitivity,
specificity, positive predictive value, negative predictive value
and accuracy of mean CIMT was 92.5%, 84.0%, 92.5% 84.0% and
89.7% respectively. The sensitivity, specificity, positive predictive
value, negative predictive value and accuracy of mean GLS was
96.2%, 68.0% , 86.4%, 89.5% and 87.2% respectively.
Coronary Angiography (CA) was performed by the
percutaneous femoral approach. Coronary angiograms were
obtained for each coronary vessel in ≥ 2 projections, and stenosis
with ≥ 70% reduction of the arterial lumen area were considered
significant. The analysis of the coronary angiograms was
performed visually by an experienced operator who was blinded
to the results of the echocardiographic examinations [11].
Ethics
Informed parental consent was obtained to be eligible for
enrollment into the study. The study was done according to the
rules of the Local Ethics Committee of Faculty of Medicine, Zagazig
University, Egypt.
Statistical Analysis
All analyses were made using the “SPSS 17 for Windows”
software package. Continuous variables were expressed as mean
± standard deviation; categorical variables were expressed as
percentages. Independent T-test was used to compare means,
ANOVA to compare multiple groups. Chi-square test was used
3/8
Figure 2: ROC curve for predicting significant CAD using GLS.
Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Copyright:
©2017 Mostafa et al.
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
4/8
Table 1: Comparison of the basic characteristic, echo and CIMT finding of the study population in patients with and without significant coronary
obstruction.
Age (y) Mean ± SD
Gender
Smoking
F n (%)
n (%)
M n (%)
Significant
Obstruction Group
(1) N= (106)
Not Significant
Obstruction Group
(2) N= (50)
X2
P
51.62 ± 8.8
53.7 ± 5.8
t= -1.09
0.28
82 (77.4%)
34 (68%)
3.4
0.07
24 (22.6%)
70 (66%)
DM
n (%)
44 (41.5%)
HTN
n (%)
16 (32%)
22 (44%)
0.78
16 (32%)
0.65
48 (45.3%)
20 (40%)
0.19
Resting ECG Positive Normal
88 (83%) 18 (17%)
26 (52%) 24 (48%)
LVESD(mm) Mean ± SD
33.26 ± 5.6
30.18 ± 3.73
GLS (%) Mean ± SD
-12.2 ± 2.93
-16.65 ± 3.5
Family history n (%)
Dyslipidemia
4 (3.8%)
n (%)
48 (45.3%)
LVEDD(mm) Mean ± SD
51.9 ± 4.7
EF (%) Mean ± SD
62.5 ± 6.5
Mean CIMT (mm) Mean ± SD
1.43 ± 0.41
4 (8%)
12 (24%)
49.9 ± 2.8
0.62
3.25
0.38
0.42
0.43
0.66
0.07
23.9
0.002
2.1
0.04
2.3
0.024
66.1 ± 6.8
-2.2
0.033
0.72 ± 0.4
7.6
0
5.8
0
LV: Left Ventricle; EDD: End Diastolic Dimension; ESD: End Systolic Diamension; EF: Ejection Fraction; GLS: Global Longitudinal Strain; CIMT: Carotid
Intimal Medial Thickness
Table 2: Angiographic findings of the study population.
Angiographic Findings
N (%)
Non significant (group 2)
50 (32.1%)
Significant (group 1)
106 (67.9%)
LCX
86 (64.2%)
LAD
RCA
SVD
DVD
TVD
102 (96.2%)
38 (35.8%)
28 (26.4%)
32 (30.2%)
46 (43.4%)
LAD: Left Anterior Descending; LCX: Left Circumflex, RCA: Right Coronary;
SVD: Single Vessel Disease; DVD: Double Vessel Disease; TVD: Triple
Vessel Disease.
Multivariate regression analysis for prediction severity of
CAD showed that CIMT is the only predictor of CAD severity (OR
125, 95% CI 5.798 - 2694.9, p = 0.002) as shown in Table 4. For
the group with normal global strain value, defined by the cutoff strain value of -15.8, carotid IMT was 0.6 ±0.3 mm and for
the group with reduced global strain values, carotid IMT was
1.4 ±0.4 mm, (t = 8.5, p < 0.000). There were significant negative
correlation between global LVGLS and mean carotid IMT (r = -0.88,
p< 0.000) and positive correlation with EF (r = 0.37, p=0.001) as
shown in Table 5 & Figure 4. GLS declined incrementally with
increasing number of stenotic coronary arteries (GLS --16.65 ±
3.5, - 14.1± 2.01, -13.7 ± 2.1* and - 9.7 ± 2.2**$) for patients with
non-significant CAD, SVD, DVD and TVD, respectively p< 0.000.
CIMT increased incrementally with increasing number of stenotic
coronary arteries (CIMT 0.72 ± 0.3, 1.15 ± 0.38, 1.4 ± 0.3 and 1.76
± 0.18) for patients with non-significant CAD, SVD, DVD and TVD,
respectively with P < 0.000 (Table 6).
Discussion
Impaired endocardial longitudinal function has been shown
to be a sensitive marker for identifying early-stage diseased
myocardium, particularly in patients with hypertrophy and
ischemia, which may be exacerbated by elevated mechanical
stress [12]. Arterial remodeling, which means larger carotid
IMT-to-lumen ratio, can result either wall thickening through
collagen matrix deposition or increased internal diameter may
share a similar pathophysiology with ventricular remodeling
and worsened myocardial deformation, which may lead to the
development of heart failure [13,14].
Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Copyright:
©2017 Mostafa et al.
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
Table 3: Diagnostic accuracy of CIMT & GLS for detetection of significant epicardial coronary stenosis.
CIMT (mm) > 1.1
GLS (%) < - 15.8
AUC
95%CI
P
Sensitivity
Specificity
PVV
NPV
Accuracy
0.89
0.81-0.96
0
92.50%
84%
92.50%
84%
89.70%
0.82
0.71-0.94
0
96.20%
Table 4: Multivariate regression analysis for prediction severity of CAD.
OR
95% CI
P
LVEDD
0.89
0.69-1.12
0.38
LVEF (%)
0.91
0.79-1.04
0.18
LVESD
GLS (%)
Mean CIMT (mm)
1.08
0.85
125
0.84-1.38
0.58-1.3
5.798 -2694.9
68%
Mean CIMT (mm)
*p: 1.000 versus SVD (non sign.)
**$p: 0.000 versus SVD&DVD
@p: 0.029 versus SVD (sign.)
89.50%
GLS (%)
R
P
0.56
LVEDD (mm)
-0.287
0.012
0.85
Mean CIMT (mm)
-0.877
0
0.002
LVESD (mm)
-0.263
EF (%)
SVD
DVD
TVD
N (50)
N (28)
N (32)
N (46)
-16.65±3.5
-14.1± 2.01
-13.7±2.1*
-9.7±2.2** $
1.15±0.38
1.4±0.3@
0.023
0.369
Not significant
0.72±0.3
87.20%
Table 5: Correlation between GLS and other parameters CIMT and EF.
Table 6: Relation between severity of coronary angiographic findings and GLS and mean CIMT.
GLS (%)
86.40%
5/8
1.76±0.18***
0.001
F
P
23.5
0
23.13
0
***p: 0.000 versus SVD&DVD (highly sign.)
Figure 4: Negative correlation between GLS and mean CIMT.
Association between GLS and severity of CAD
Figure 3: ROC curve for predicting significant CAD using CIMT.
We found that GLS was significantly lower among patients
with significant CAD (> 70%) than those with non-significant CAD
(<70%) with mean values of GLS were (- 12.2 ± 2.93 vs -16.65 ±
3.5, p < 0.000). This finding was similar to the results reported by
Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
previous studies [15- 20]. We found that GLS less than -15.8 %
may predict of significant obstructive CAD (>70%) in 87.2 % of
patients with sensitivity 96.2% and specificity 68.0% as shown
Table 3, Figure 2. So we concluded that GLS measurements had
high diagnostic accuracy in predicting significant CAD among
patients presenting with stable chest pain. These findings were
different from previous studies 15-20 as they found that GLS
measurements only have modest diagnostic accuracy in predicting
obstructive CAD. This difference may be explained by lower cutoff
value of GLS (-15.8 %) in our study compared to other studies
where their cut-off level of GLS varied between -17.4 % and - 19.7
%.
Shimoni et al. [15] showed that GLS ≤ -19.7 may predict
significant obstruction (>50%) of CAD with sensitivity 81%
and specificity 67%. Montgomery et al. [16] found that GLS ≤
-17.8 may predict significant obstruction (>50%) of CAD, with
sensitivity 66% and specificity 76%. Biering- Soerensen et al. [17]
showed that cut-off level of GLS was ≤ -18.4% for prediction of
significant CAD (>70%) with sensitivity 74% and specificity 58%.
Evensen et al. [18] found the endocardial strain GLS value less than
-16.7% may predict significant obstruction (>50%) of CAD with
sensitivity 80% and specificity 60%. Billehaug Norum et al. [19]
used 6 studies (778 patients with suspected CAD). They found the
cut-off level of GLS for prediction of CAD+ varied between -17.4 %
and -19.7 % with a sensitivity from 51 % to 81 % and specifcity
between 58 % to 81 %. So they concluded GLS measurements
at rest only have modest diagnostic accuracy in predicting
CAD+ among patients presenting with chest pain. These finding
possibly could be explained by the effect of diastolic function and
afterload on GLS, and there were overlap in distribution of GLS
values between the CAD+ and CAD- groups. Gaibazzi et al. [20]
found that GLS using vendor-independent software, has similar
accuracy compared with stress-echo wall motion analysis for
the prediction of significant CAD. They concluded that GLS ≤
-20.7 may predict significant obstruction (>50%) of CAD, with
sensitivity 81.6% and specificity 84.9%.
The optimal GLS diagnostic cutoff value varies significantly
among previous studies could be explained by GLS may depend
on the clinical characteristics of patients, the effect of diastolic
function and their hemodynamic parameters (i.e. blood pressure)
during image acquisition [21], by using different equipment,
different design, vendor-dependent 2D-STE software and
operator skills [16,22,23]. Another data have indicated that GLS
is more dependent on the 2D-STE software used, rather than
ultrasound equipment used to acquire images [24-26]; which
makes the use of vendor-independent software particularly
attractive to standardize GLS for widespread use. The possibility
of using a fixed diagnostic GLS cutoff value to diagnose obstructive
CAD, independent of the ultrasound equipment used for images
acquisition, would be required to increase the clinical usefulness
of strain imaging. We found that GLS declined incrementally
with increasing severity of CAD defined by increasing number
of stenotic coronary vessels. This finding was similar to results
of Biering- Soerensen et al. [17] and also the studies reported by
Gaibazzi et al. [20] and Choi et al. [22] which showed similar GLS
values through different CAD categories. Patients with normal
Copyright:
©2017 Mostafa et al.
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coronaries had a mean GLS of -22 ±1.5%, single or double vessel
disease -19.4 ± 2.4 %, and triple-vessel or left main disease -18 ±
2.3%.
Correlation between CIMT and GLS
Our study found that for the patients with normal global strain
value, defined by the cut-off strain value of ≥ -15.8 %, the carotid
IMT was 0.6 ±0.3 mm and for the patients with reduced GLS values
< -15.8 %, the carotid IMT value was 1.4 ±0.4 mm (p < 0.000). Also
we found that GLS had highly significant negative correlation with
mean CIMT (p < 0.000). Fernandes et al. [27] support our result as
their MESA study is a prospective observational study including
four ethnic groups free from clinical cardiovascular disease using
tagged MRI for assessement of LV function. They found increased
carotid IMT was associated with alterations of myocardial
strain parameters reflecting reduced systolic and diastolic
myocardial function. These observations indicate a relationship
between subclinical atherosclerosis and incipient myocardial
dysfunction in a population free of clinical heart disease. Liao et
al. [28] demonstrated that enlarged carotid artery diameter was
associated with reduction of myocardial deformation indices
including global longitudinal, circumferential and radial strain
in subjects with hypertension (HTN) and heart failure with
preserved ejection fraction (HFpEF), so it could be a useful clinical
marker in early identifying ventricular functional decline. Evensen
et al. [18] support our results as they found increased carotid IMT
values were associated with decreased left ventricular function
they stated that the group with normal endocardial strain, defined
by the cut-off strain value of -16.7, carotid IMT was 1.2 mm ± 0.2
and for the group with reduced strain, the carotid IMT was 1.7
mm ± 0.5. There was significant correlation between endocardial
LVGLS and maximum carotid IMT (p = 0.006).
Therefore, the presence of increased carotid IMT may lead to
detection of very early cardiac dysfunction which may benefit
from cardiovascular risk management. B-mode ultrasound of
the carotid artery is a non-invasive, inexpensive and widely used
examination and may therefore be an additional appropriate tool
for the assessment of possible CAD. IMT measurements in patients
with cardiovascular risk factors may therefore be of value when
estimating the risk of subclinical coronary artery disease.
Correlation between GLS and EF
We found that patients with significant CAD had significant
decrease of left ventricle ejection fraction [62.5 ± 6.5 vs 66.1 ± 6.8,
p = 0.033] compared to patients with non-significant CAD. This
finding is in agreement with Sharma et al. [29]. The present study
found that GLS had highly significant positive correlation with
EF (r = 0.37, p = 0.001). This result in concordant with results of,
Biering- Soerensen et al. [17], Evensen et al. [18] and Delgado et
al. [30].
Delgado et al. [30] showed a good correlation between GLS and
biplane LVEF for the overall study population, 222 patients with
CAD (r = 0.83; p< 0.001). However, in patients with STEMI and
patients with heart failure the correlation was less strong (r = 0.42
and r = 0.62) respectively suggesting that these two parameters
reflect different aspects of systolic LV function.
Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
Association between CIMT and severity of CAD
The present study showed carotid artery IMT was higher in
patients with significant CAD + >70% (1.43 ± 0.41 vs 0.72 ± 0.4,
p< 0.000) compared to group 2 with non-significant CAD This
finding was similar to the results reported by previous studies
[18,31-33]. Thickening of the carotid intima-media (CIMT) to
just over 1.1 mm may prove to be predictive of significant CAD in
nearly 89.7% of patients with sensitivity (92.5%) and specificity
(84.0%). There was incremental significant increase in CIMT
with increasing severity of CAD defined by increasing number
of stenotic coronary vessels. Tarzamni et al. [31], found that the
mean CIMT was (0.83±0.26) in significant CAD (stenosis >70%)
compared to (0.53±0.16) in non significant CAD (p=0.001).
Holland et al. [32], reported that a maximal CIMT value of 0.956
mm had 85.7% sensitivity and 85.1% specificity to predict
angiographic CAD. Coskun et al. [33] showed CIMT was higher
in patients with significant CAD (1.48 ± 0.28 mm vs 0.78 ± 0.21
mm). CIMT thickening > 1.0 was predictive of significant (> 50%)
CAD. They found the mean CIMT was significantly higher in CAD
+ groups, with single vessel disease, multi-vessel disease, and left
main CAD compared to CAD - group (0.78mm) (1.2 ± 0.34 mm, p
= 0.02; 1.6 ± 0.32 mm, p = 0.001; and 1.8 ± 0.31 mm, p = 0.0001,
respectively.
Limitations
1) Small sample size 2) Since the study was cross-sectional,
the clinical endpoints were not followed so prognostic value of
GlS not determined 3) Potential selection bias due to the need to
enroll only patients with normal resting wall motion 4) Segmental
RLS was not assessed because there were different methods used
for obtaining regional strain. as a 16-segment or a 17-segment
anatomical model for LV so the results represent a problem as
this anatomical model does not necessarily reflect the individual
coronary artery distribution because there is individual variability
in the coronary blood supply to myocardial segment, also we need
for proper standardization of how to uniformly obtain regional
longitudinal strain (RLS) data.
Conclusion
Increased carotid IMT values were associated with decreased
left ventricular strain function. So the presence of increased IMT
may lead to detection of very early cardiac dysfunction which may
benefit from cardiovascular risk management. These findings
support the use of carotid IMT measurements to predict the risk
of coronary heart disease. In patients with suspected coronary
artery disease, GLS assessed by 2D-STE at rest can predict
significant CAD. So, 2D-STE has the potential to improve the
value of echocardiography in the detection of the CAD, identifying
high-risk patients and to provide more information for clinical
physician. Increased CIMT is associated with the presence and
extent of CAD. Patients with a mean CIMT over 1.1 mm have a high
likelihood (90 %) of significant CAD. So ultrasound examination
of the carotid arteries can effectively predict atherosclerosis of the
coronary arteries.
Copyright:
©2017 Mostafa et al.
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Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268
Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic
Strain in Patients with Coronary Artery Disease
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Citation: Mostafa T, Radwan H (2017) Carotid Artery Intimal-Medial Thickness and Left Ventricular Longitudinal Systolic Strain in Patients with
Coronary Artery Disease. J Cardiol Curr Res 8(1): 00268. DOI: 10.15406/jccr.2017.08.00268